Healthcare Provider Details

I. General information

NPI: 1366814667
Provider Name (Legal Business Name): UNM-PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2015
Last Update Date: 10/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 MARBLE AVE NE
ALBUQUERQUE NM
87106-2058
US

IV. Provider business mailing address

2600 MARBLE AVE NE
ALBUQUERQUE NM
87106-2058
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-0271
  • Fax: 505-272-4563
Mailing address:
  • Phone: 505-272-0271
  • Fax: 505-272-4623

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number261QM0850X
License Number StateNM

VIII. Authorized Official

Name: MRS. ANNETTE J. LICHT
Title or Position: REGISTERED NURSE
Credential: RN
Phone: 505-272-0271